Chronic obstructive pulmonary disease (COPD) is a diverse lung condition marked by chronic respiratory symptoms because of airway abnormalities, ending in persistent and often worsening airflow limitation (Agusti & Vogelmeier 2023). Its management has multiple approaches combining medical therapy with pulmonary rehabilitation (PR) associated with lifestyle modifications (Venkatesan 2024).

Patients with COPD tend to be less physically active compared to individuals of the same age group. This inactivity is often driven by a growing fear of physical exertion. As a result, their physical capabilities decline, particularly in areas such as endurance, coordination and balance (Hanania & O’Donnell 2019). In addition, the muscles in their lower limbs undergo atrophy, characterised by a reduction in muscle fibre size and a decrease in mitochondrial density. This loss of mitochondria, which are crucial for energy production, contributes to further muscular deconditioning and weakness (Henrot et al. 2023).

All these lead to a decline in lung function and recurrent exacerbations, which are common in patients with COPD that end with hospital readmission and a high socioeconomic burden (Hurst et al. 2020; Tachkov et al. 2017).

The health and social consequences of COPD underscore the importance of implementing cost-effective interventions and secondary prevention strategies to reduce its side effects. In this context, engaging in physical activity and exercise-based interventions is a cost-effective approach, offering significant improvements in quality of life (Ramos et al. 2019).

Pulmonary rehabilitation, which includes structured exercise training, is recognised as a cornerstone of COPD management (Evans & Steiner 2017). Experts emphasise that PR provides broad benefits across all stages of COPD, even in the presence of multiple comorbidities, and it improves various health-related outcomes (Agusti & Vogelmeier 2023, Houben-Wilke et al. 2017), resulting in exacerbation and hospitalisation reduction (Shu et al. 2021). However, maintaining physically active behaviours and adherence to such programmes after completing PR remains low and poses a significant challenge, particularly in patients with severe COPD, as they struggle with poor health and multiple comorbidities. So the gains achieved during PR often diminish within 6–12 months after the programme ends (Blindenbach et al. 2017; Malaguti et al. 2021). This causes muscular atrophy and leads to limitations in physical functioning, endurance and activity (Hsieh, Yang & Tsai 2016).

Therefore, a home-based programme is another method of integrating PR into daily living patterns and may facilitate adherence as an alternative to removing most of the limitations.

It enhances patients’ self-confidence, breaks down ‘psychological barriers’ and promotes long-term adherence to healthier behaviours (Meshe 2023). By facilitating a shift towards positive lifestyle changes, it also helps to reduce financial burdens. Because rehabilitation programmes are designed around everyday activities, it is easy to simplify, explain and supervise this therapy (Yohannes et al. 2021).

Recent studies have demonstrated that implementing a home-based rehabilitation programme can effectively maintain and enhance the self-confidence and quality of life of patients with COPD, in comparison to traditional rehabilitation (Belloumi et al. 2024).

So, we conducted our study to assess the effectiveness of a home-based PR programme in patients with severe COPD and whether it provides a significant benefit to physical and respiratory functions.

Forty-seven COPD (GOLD IV) patients were enrolled in the study; 7 of them were excluded because of having respiratory exacerbation with a need for hospital admission during the inclusion period, and 40 patients completed the study. We analysed data from patients at baseline, before the beginning of PR and after 3 weeks of the home-based PR programme.

We conducted our study to assess the effectiveness of a home-based PR programme in severe COPD patients and whether it provides a significant benefit to physical and respiratory functions.

It is widely recognised that individuals with COPD tend to be less physically active compared to their peers in the same age group, often because of a heightened fear of physical exertion linked to dyspnoea (Hanania & O’Donnell 2019). However, participation in physical activity and exercise-based interventions is a cost-effective approach, yielding significant improvements in quality of life (Ramos et al. 2019).

These fears, in association with multiple comorbidities, COPD acute exacerbations and increased financial costs, make the adherence to PR programmes a challenge for these patients, especially in severe COPD cases. This is supported by Belloumi et al. (2024), who demonstrated that poor adherence negatively affects dyspnoea scores, and by Braeken et al. (2017), who found that severe acute exacerbations are associated with non-completion of the programme.

Despite all these limitations, multiple studies recommend a long-term rehabilitation programme for persistent results; Lan et al.’s (2018) study proved that the benefits of long periods of PR tend to decline over the years when PR stops, and maintenance of PR is associated with greater benefits. A 2-year follow-up study by Yohannes et al. (2021) for COPD patients showed that maintained exercise programmes sustain an improvement in anxiety and quality of life. Similarly, the study by Candemir, Ergün and Şahin (2021) showed clinically maintained improvements in exercise capacity and health-related quality of life after 1 year of PR.

These findings highlight the need for home-based programmes as a possible solution for most of the limitations and a suitable alternative with many benefits. In this context, our results are promising, as we observed that although our patients were severe COPD cases, they showed associated improvements in dyspnoea grade (mMRC), CAT score, Barthel score and 6MWT. The severity of dyspnoea was reduced, with the majority of patients reaching grades I and II (40% and 37.5%, respectively) compared to the pre-programme assessment when 47.5% of them were in grade III category. The CAT score improved significantly from 26.95 ± 3.61 to 21.85 ± 3.94. This suggests that a maintained PR programme may be associated with positive outcomes, even in GOLD IV patients.

This is similar to Cheng et al. (2014), who found that patients with severe COPD who followed a PR programme experienced minimal dyspnoea at the end of the study. Exercise training is the preferred method to improve dyspnoea, as it addresses both its psychological and physiological aspects. The improvement in dyspnoea is largely attributed to enhanced tolerance and adaptation to exercise at a muscular and cellular level, particularly involving mitochondria in skeletal muscles, including the primary and accessory respiratory muscles. Furthermore, exercise training enhances cardiac autonomic function and reduces lung hyperinflation (Leite et al. 2015). Our study showed a statistically significant change in SpO₂ after PR, indicating reduced exertional desaturation, which could be clinically relevant in patients with respiratory compromise.

The patients’ quality of life improved, as indicated by the HS improvement in Barthel score. This is similar to the study by Li et al. (2019), which involved 414 elderly patients and demonstrated that PR led to significant improvements in exercise capacity and quality of life. The researchers observed that the enhancement in quality of life was linked to a reduced fall risk. It showed that both ageing and chest diseases (e.g. COPD) negatively impact postural control. However, various exercises that enhance physical capacities, sensorimotor strategies, postural stability and respiratory function have been shown to reduce the frequency of falls, even in the absence of balance-specific exercise programmes (Boffino et al. 2019).

Our findings are similar to those of Spielmanns et al. (2023), who reported that participation in a PR led to significant improvements in the assessed parameters in patients with COPD, regardless of age group, including those over 80 years. Similarly, Belloumi et al. (2024) found a difference in dyspnoea scores, especially in adherent compared to non-adherent patients.

Our exercise programme was tailored according to each patient’s condition, allowing flexibility in selecting the level of exercise intensity, the number of repetitions and the number of sessions per week. Hansen et al. (2020) state that the ultimate objective of PR is to enhance patient autonomy, improve exercise capacity and reduce the limitations imposed by their respiratory condition, promoting long-term adherence. In our study, the mean adherence was about 95%, indicating good compliance and demonstrating a high level of engagement and feasibility of the tailored home-based exercise protocol.

Most of our exercises were low intensity to maximise physiological effects while considering the impact of ageing and the severity of COPD. In addition, long-term adherence is associated with low-intensity training (Gloeckl, Marinov & Pitta 2013). Breathing exercises such as diaphragmatic breathing and pursed-lips breathing were recommended for patients unable to engage in physical exercise. These techniques have the potential to improve pulmonary function, exercise endurance, dyspnoea, quality of life and respiratory muscle strength in COPD patients (Ceyhan & Tekinsoy 2022; Junita et al. 2022).

Implementing home-based rehabilitation programmes enables physicians to extend care to a larger number of patients than would be possible through traditional rehabilitation centres. This approach supports cost-effective interventions as part of secondary prevention strategies, helping to reduce the risk of developing COPD or experiencing exacerbations, thereby lowering the likelihood of rehospitalisations. These programmes typically involve mild-intensity exercises with adjustable intensity levels to ensure patient safety, build self-confidence and gradually progress to higher intensity aerobic workouts. Home-based rehabilitation is particularly beneficial for patients who face barriers to accessing clinical settings or during pandemics when gatherings are risky or impractical.

A key strength of our study is the inclusion of elderly patients with advanced (severe) COPD, a population that faces significant challenges in maintaining daily activities because of both ageing and the underlying lung disease. Our study provides preliminary evidence that targeting this vulnerable subset of the population with a simple, yet effective, home-based PR programme is a promising approach.

However, our study has some limitations. Although our study included a statistically representative sample size, as determined by an expert statistician at our institution, the relatively small number of participants may still limit the generalisability of the findings. Furthermore, the number of sets and the intensity of exercises were different, tailored according to each patient’s ability and fitness. We did not have a comparable control group.

These limitations suggest that our results be interpreted with some caution.

Home-based, low-intensity PR programmes could be beneficial in severe COPD and can serve as an alternative in case of difficulties in attending clinical settings.